Flaccid paralysis of the upper extremities

Introduction One of the symptoms of brachial plexus injury, total brachial plexus injury: early all the upper limbs were delayed paralysis. Brachial plexus is a common type of peripheral nerve injury. Generally divided into upper brachial plexus injury (Erb injury), lower brachial plexus injury (Klumpke injury) and total brachial plexus injury. In 1985, Leffert made the following classification according to the mechanism of the brachial plexus injury and the injury site: 1. open brachial plexus injury; 2. closed (pull) brachial plexus injury; (1) supraclavicular brachial plexus injury 1 ganglion above brachial plexus injury (pre-holiday injury) 2 brachial plexus injury (post-ganglionic injury); (2) subclavian brachial plexus injury; 3. radioactive brachial plexus injury; 4. calving.

Cause

(1) Causes of the disease

Brachial plexus injuries are mostly:

1 pulling injury: the upper limb was wounded by a belt;

2 pairs of bruises: if hit by a fast car hitting the shoulder or shoulder by a flying stone;

3 cutting injury or gunshot wound;

4 crush injury: such as clavicle fracture or shoulder lock is squeezed;

5 birth injury: abnormal fetal position during childbirth or traction during labor.

(two) pathogenesis

The most common cause and pathological mechanism of brachial plexus injury is traction injury. Most of the adult brachial plexus injuries (about 80%) are secondary to motorcycle or car accidents. If the motorcycle collides with the car, the motorcycle hits the roadside obstacle or the big tree, the driver is injured and falls to the ground, the head and shoulders hit the obstacle or the ground, so that the head and shoulders are separated, and the brachial plexus is over-exposed. Injury, mild nerve concussion, temporary dysfunction, severe axon rupture, nerve root cads rupture, the heaviest can cause 5 nerve roots to break from the spinal cord, like "pull radish" avulsion, complete loss Features. When the worker accidentally pulls the upper limb into the machine, belt or transport belt, the external armor can cause damage to the brachial plexus due to the instinctive reflection of the human body, causing the upper trunk to be damaged by the upward winding, and the full brachial plexus is caused by the horizontal involvement. damage. Heavy falls on the landslides or heights of the mines, falling on the shoulders, impacting the shoulders during high-speed movements, etc. can also damage the brachial plexus. Neonatal brachial plexus injury is seen in the mother's dystocia, the baby's weight is generally more than 4kg, the first exposed, the use of the first tire suction device or the use of forceps, resulting in the baby's head and shoulder separation, excessive traction and damage to the brachial plexus, mostly not Complete damage.

Brachial plexus injury is also seen in gunshot wounds such as shoulder and neck bullets, shrapnel and other firearms or blind tube injuries, knife stab wounds, glass cuts, drug damage and surgical accidental injuries. Such injuries are more limited, but the degree of injury is more serious, mostly the nerve root cads fracture. May be associated with subclavian, aortic vein and other injuries. Clavicle fractures, anterior shoulder dislocation, cervical ribs, anterior scalene syndrome, primary or metastatic tumors near the brachial plexus can also compress the brachial plexus.

an examination

Related inspection

X-ray lipiodol angiography CT examination magnetic resonance scan

According to the unique symptoms and signs of different nerve branches, combined with trauma history, anatomical relationship and special examination, the injured nerve and its damage plane and degree of injury can be determined. The diagnosis of brachial plexus injury, including clinical, electrophysiological, and imaging diagnosis, is also required for intraoperative diagnosis of brachial plexus injuries that require surgical exploration. The procedure for brachial plexus injury diagnosis is as follows.

1. Determine the presence or absence of brachial plexus injury

The presence of brachial plexus injuries should be considered when the following conditions occur:

(1) Joint injury of any 2 of the upper limb 5 nerves (, musculo, median, iliac crest, ruler) (non-identical cutting injury).

(2) Any of the 3 nerves (median, sacral, and ulnar) of the hand is associated with dysfunction of the shoulder joint or elbow joint (passive activity is normal).

(3) Any of the 3 nerves (median, sacral, and ulnar) of the hand combined with the medial cutaneous nerve injury of the forearm (non-cut injury).

2. Determine the brachial plexus injury site

Clinically, the clavicle muscle clavicle represents the neck 5, 6 latissimus dorsi represents the neck 7, and the pectoralis major muscle rib represents the neck 8 chest 1. The above muscle atrophy indicates that the injury is on the clavicle, that is, the root and cadre damage. The presence of the above-mentioned muscle function indicates that the injury is under the clavicle, that is, the bundle branch is damaged. This is an important basis for identifying damage above and below the collarbone.

3. Positioning diagnosis

(1) Brachial plexus root injury:

1 Upper brachial plexus (neck 5 ~ 7) injury: sputum, musculocutaneous, scapular sacral: sacral scapular nerve paralysis, sputum, median nerve part paralysis. The shoulder joint can not be abducted and lifted. The elbow joint can not be flexed. Although the wrist joint is flexed and stretched, the muscle strength is weakened, the forearm rotation is also obstructed, the finger movement is normal, and the upper limb extension surface feels mostly missing. The deltoid muscle, the superior and inferior muscles, the scapula levator muscle, the large and small rhomboid muscle, the radial flexor digitorum, the pronated round muscle, the diaphragm, the supinator muscle, etc. appear sputum or part of the sputum.

2 lower brachial plexus (neck 8 chest 1) injury: ulnar nerve palsy, medial cutaneous nerve of the arm, medial cutaneous nerve of the forearm, paralysis of the median and sacral nerves. The function of the hand is lost or severe obstacles occur. The shoulder, elbow and wrist joints are still active, and the Horner sign often appears on the affected side. The muscles in the hand are all atrophied, the interosseous muscles are particularly obvious, the fingers can not flex or stretch or have serious obstacles, the thumb can not be abducted on the volar side, and the skin of the forearm and hand ulnar side is missing. The ulnar wrist flexor, the deep and shallow flexor muscles, the large and small muscle groups, all the sacral muscles and the interosseous muscles appear paralysis. The triceps and forearm extensor muscles are partially paralyzed.

3 total brachial plexus injury: early all the upper limbs were delayed paralysis, the joints could not actively move, but the passive movement was normal. Since the trapezius muscle is dominated by the accessory nerve, shrugging motion can exist. The upper extremity felt that the medial side of the arm was lost due to the presence of the intercostal brachial nerve from the second nerve. The upper extremity tendon reflexes disappeared, the temperature was slightly lower, and the distal extremity was swollen. Horner sign positive. In the late stage, the upper limb muscles were significantly atrophied, and the joints were often restricted by passive movement due to contracture of the joint capsule, especially the shoulder joint and the knuckle joint.

(2) brachial plexus injury:

1 Upper dry injury: its clinical symptoms and signs are similar to the upper brachial plexus root injury.

2 dry injury: independent injury is rare, but can be seen in the correction of the neck 7 nerve root displacement repair to cut the neck 7 nerve root or the middle dry. Only the indications, the middle finger refers to abdominal numbness, the muscle strength of the extensor muscles is weakened, etc., and can gradually recover after 2 weeks.

3 dry injury: its clinical symptoms and signs and lower brachial plexus root injury are similar.

(3) brachial plexus injury:

1 lateral bundle injury: musculocutaneous, medial nerve root and anterior thoracic nerve paralysis. The elbow joint can not be flexed, or it can be flexed (the diaphragmatic muscle compensation) but the biceps muscle paralysis; the forearm can be pre-rotating but the anterior circumflex muscle paralysis, the wrist joint can be flexed but the radial wrist flexor muscle paralysis, other joints of the upper limb The activity is still normal. The lateral edge of the forearm is missing. The biceps, the radial flexor digitorum, the pronated round muscle and the pectoralis major clavicle, the movement of the shoulder joint and the hand joints are normal.

2 medial bundle injury: ulnar, medial root of median nerve and anterior medial nerve palsy. The internal muscles of the hand and the forearm flexor muscles are all paralyzed, the fingers can not flex and stretch, the thumb can not be abducted on the palm side, and the palm and the fingers cannot be used. The inner side of the upper limb and the ulnar side of the hand disappeared. The hand has a flat hand and a claw-shaped hand deformity. The shoulder and elbow joints function normally. The medial bundle injury and the neck 8 thoracic 1 nerve root injury behaved similarly, but the latter often had the Horner's sign, and the triceps and forearm extensor muscles were partially paralyzed.

3 posterior bundle injury: sputum, sputum, chest and back, scapular nerve paralysis, deltoid muscle, small round muscle, extensor muscle group, latissimus dorsi, subscapularis muscle, large round tendon. The shoulder joint can not be abducted, the upper arm can not be rotated, the elbow and wrist joint can not be extended, the metacarpophalangeal joint can not be straightened, the thumb can not be straightened and the temporal side is abducted, the lateral side of the shoulder, the back of the forearm and the lateral side of the back of the hand are not able to move or Lost.

Differential diagnosis

Proximal Limb Muscles and Respiratory Paralysis: A group of syndromes in which muscles and respiratory paralysis of the cranial nerves are caused by proximal muscles of the extremities, III-VII and X by dysfunction of postsynaptic neuromuscular junctions.

Stinging or numbness in the fingers or arms: Patients with cervical spinal stenosis complained that there are fingers (mostly at the fingertips) or pain and numbness in the arm when the disease is first developed, especially tingling.

Paralysis: Generalized paralysis refers to a state in which the function of the cells, tissues, and organs of the body declines and does not respond to the stimulus. Narrowly defined paralysis refers to the decline of the function of the nervous system, especially the motor nervous system. Sports paralysis can be divided into complete paralysis and incomplete paralysis according to the degree; according to the nature can be divided into central (sexual) paralysis and peripheral (slow) paralysis. Central paralysis is a disorder that is emitted from the cerebral cortex to the first neuron of the spinal cord, the pyramidal pathway; peripheral paralysis is a disorder that is emitted from the anterior horn of the spinal cord to the second neuron of the skeletal muscle.

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